Published October 15, 2012
On the issue of health care reform, your choice on Election Day comes down to Obamacare or "repeal and replace."
President Barack Obama's position can be "summed up" in 2,400 pages. That's the length of his Affordable Care Act, the landmark 2010 health care overhaul informally known as Obamacare, which makes sweeping consumer-centric changes to common health insurance practices.
The law is closely modeled after the Massachusetts health insurance reform that Republican challenger Mitt Romney championed when he was governor of that state in 2006. But now, the former Massachusetts governor vows that if he's elected president, he'll repeal the Obama law and replace it with a more conservative alternative. But what that might look like is one of the campaign's big questions.
Obama touts health care law in his campaign
Obama is promoting the Affordable Care Act as he makes his case for a second term. Go to the health care section of his campaign website to find out where he stands, and what you'll find are links where you can "learn how Obamacare benefits you."
Under the law, insurers by 2014 may no longer: deny coverage to individuals with pre-existing conditions; impose lifetime or annual dollar limits on coverage; cancel coverage arbitrarily; limit doctor choice and out-of-network emergency services; or charge higher premiums based on gender or health status.
The act also allows young adults to remain on their parents' policy until age 26, and it provides a laundry list of preventive care screenings and services to all ages at no additional cost.
To help pay for this expansion of benefits, the law's "individual mandate" requires most Americans to obtain health insurance or pay a penalty. To help consumers find affordable coverage, new state marketplaces called exchanges will open in 2014, government tax credits will be available for low-income individuals and families, and states are encouraged to expand their Medicaid programs to millions of uninsured, lower-income Americans.
The Medicaid expansion had been a requirement under the law, but the U.S. Supreme Court made it optional for states.
Romney plan short on details
Romney's campaign website says Obama's approach to health care reform takes the country in the wrong direction, by relying on "a dense web of regulations, fees, subsidies, excise taxes, exchanges, and rule-setting boards to give the federal government extraordinary control over every corner of the health care system."
But while the Republican has been very specific about wanting to repeal the Obama health care law, he has been vague on how a Romney administration would replace it, says Jonathan Oberlander, professor of social medicine and health policy at The University of North Carolina at Chapel Hill.
"On one hand, there is reason to think they might seek ambitious health reform. On the other hand, the base of the Republican Party is more interested in 'repeal.' That makes it very hard for him to talk specifics about 'replace,'" Oberlander says.
Romney "would be part of a Republican government, and the Republican Party has shown some pretty strong preferences about health care," according to Joe White, professor of public policy and political science at Case Western Reserve University in Cleveland.
According to the Romney website, his reforms would promote individual responsibility for health care and ease government regulation on health insurers so that free-market competition can drive down costs.
The states rather than the federal government would run the show and "have both the incentive and the flexibility to experiment, learn from one another, and craft the approaches best suited to their own citizens," the website says. Federal standards and requirements would be limited on both private insurance and Medicaid.
"The Republican position all along has been that the problem with health care is that people are not individually responsible for their health care, so when they need it, they consume too much," White says. "Basically, their solution is to encourage less generous or less adequate insurance."
Romney has said he would retain some popular features of the Affordable Care Act, including allowing young adults to remain on their parents' plan and enabling people with pre-existing conditions to obtain coverage. But while he has said, "I like everybody being insured," it is unclear whether he would require that.
What do voters want?
The Obama law is already starting to transform U.S. health care into the president's vision, to mixed reviews. In a recent tracking poll from the Kaiser Family Foundation, 43% of Americans viewed the law unfavorably, while 38% felt favorably.
What effect would a Romney overhaul of the overhaul have on U.S. health care, and would the public approve?
Judy Feder, health policy expert with the Urban Institute, a nonpartisan think tank in Washington, D.C., says stripping the market of regulation would leave consumers less empowered to find affordable health coverage.
"It would essentially undo the employer-based insurance market," she says. "Individual shoppers are much less effective than larger purchasers, particularly in a highly concentrated health care market."
In the Kaiser Family Foundation tracking poll, a 49% plurality said the Affordable Care Act should be kept as is or even expanded. Oberlander says whether voters would accept a Republican health insurance alternative may not be as important to a President Romney as whether he could convince his own party to act at all.
"If he wins, he's got more freedom, but they would also face a very conservative House, and they're certainly not going to have a 60-vote (filibuster-proof) majority in the Senate," Oberlander says, of the challenges for a Republican White House on health care reform. "Even if they wanted to do something ambitious, how do you pass it? And from a purely political viewpoint, why in the world would anybody want to start another health reform fight?"